SYMPHONY Person-Centred, Co-ordinated Care

Jeremy Martin, Andrew Street

@SymphonyProj @andrewdstreet

19 GP practices 4 community hospitals Community mental health team 1 district general hospital Poor public transport Predominantly small market towns and villages

About South Somerset

The Project Board

Alliance Partners

Commissioners

Somerset CCG

Somerset County Council

Bristol, North Somerset, Somerset and South Gloucestershire Area Team

Providers

Yeovil District Hospital NHS Foundation Trust

Somerset Partnership NHS Foundation Trust

Symphony Primary Care Group

Adult Social Care

Other Project Board Members

South Western Ambulance NHS Foundation Trust

South West Commissioning Support Unit

South Somerset District Council

North Dorset CCG

Key Symphony Components

1. Evidence – individual level data set

2. Shared outcomes

3. Care model

Primary purpose of data analysis

• Identify people who might benefit from integrated financial arrangements

– Those using care across multiple settings

– Those with multi-morbidity profiles

– Large enough group to form risk pool

– Costs of the group offer potential scope for savings

Anonymised data at patient level (n=115k) for full year about their: Utilisation of health and social care, with data linked across eight broad settings of care. 1. Costs according to type of care received in each

setting. 2. Demographic characteristics, including age, gender,

socio-economic status. 3. Indicators of morbidity.

Describing multi-morbidity 1. Constructed using United Health’s RISC tool

• used to assess risk of unplanned hospital admissions

2. Uses diagnostic information in patient hospital and general practice records

• ICD10 and Read codes 3. Summarised into 586 conditions

• Episode Treatment Groups (ETGs)

4. We identified 49 ETGs as chronic conditions 5. GPs said 12 of these particularly important

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+

Pat

ien

ts (

%)

Age band (Years)

Morbidity (number of ETGs) by age band

0

1

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Number ofconditions

Regression variables

Age Number of

chronic conditions

Age, Number of

chronic conditions

Variation explained 3.36% 10.48% 10.66%

Regression variables

Age Number of Conditions

Age, Number of conditions

Variation explained 3.36% 19.80% 19.80%

• Health and social care costs increase as people get older

• But as people get older, they have more co-morbidities

• Costs increase the more co-morbidities a person has

• Costs are explained more by the number of chronic co-morbidities (11%) than by age (3%)

Single and multi-morbidity

• Conditions vary in whether they are single or multi-morbidity

– Hypertension: 30% single morbidity

– Asthma: 50%

– Diabetes: 15%

– Stroke: 10%

– COPD: 10%

Diabetes

• 5,676 people are recorded as having diabetes in South Somerset, their total costs amounting to £17m

• For those with this sole diagnosis, costs are around £1,000 on average

• Hypertension is the most common comorbidity for people with diabetes

• As people are recorded as having more diagnoses, average costs increase progressively faster

Dementia

• 1,062 People with dementia - 0.92% of the South Somerset population

• Total costs amount to £13m – 11% total budget

• No obvious pattern between the number of conditions and average costs

• Costs predominantly social care and continuing care

Regression analysis

• Log-linear or two-part models

• Explanatory variables:

– Age

– Gender

– Social deprivation

– Whether patients died during the year

– Whether patients or moved elsewhere

– Number of chronic conditions

– Twelve specific chronic conditions

Total costs Variable Diabetes Dementia

Age 0.006*** 0.01

Male -0.100*** -0.10

Deprivation 0.003 0.02***

Number of co-morbidities 0.263*** 0.14***

Died 1.188*** 0.67***

Moved elsewhere -0.095 0.07

Dementia / diabetes 0.937*** 0.08

Mental health (exc dementia) 0.069 0.23

Cancer 0.176*** -0.18

Cardio-vascular disease 0.207*** -0.09

Stroke 0.163*** 0.23*

Obesity 0.562*** 1.37

Respiratory problems 0.138** 0.30*

Gastric problems 0.134* 0.00

Trauma/burns/fractures 0.382*** 0.61***

Arthritis -0.030 -0.59

Renal problems 0.569*** 0.54**

Calculate budget requirements

• Budget = Number of people × average cost

• What if people are more complex next year?

• Use model parameters to calculate “risk adjusted” budget

Model budget impact of change in service provision

• What are cost implications of (say) 5% reduction in hospital admissions?

– Where is care delivered instead? Analyse provision across settings

– Are those affected atypical? Model costs changing patient characteristics

– Are providers able to realise cost savings?

Conclusions

• Multi-morbidity better than age at explaining costs

• Identify people who might benefit from integrated financial arrangements

• Calculate budget to support integrated care

• Model implications of change in service delivery

How the data analysis shaped the Symphony Project

• Changed focus from frail elderly to adults with several conditions

• Influenced decision to develop a multi-morbidity model of care

• Influenced choice of starting cohort

• Key enabler for a capitated budget

• Generated buy-in from clinical staff

• Attracted national interest and investment

Key Symphony Components

1. Evidence – individual level data set

2. Shared outcomes

3. Care model

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What matters

Sought ideas from people with lived experience and current frontline staff. • Reviewed national and local

publications • Held one-to-one interviews

with people with long term conditions

• Facilitated event with people, carers and frontline staff.

Insights about what works well now, what people hope to see more/less of in the future

People and carers’ shared hopes:

Staff’s shared hopes:

Insights used to guide design work and formulate the outcome set

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Focus Me and my carer (s), taking account of all my conditions and our physical, mental, social and emotional needs

Outcome I am helped to manage my conditions and live in the way I want to the best of my ability

Features ACTIVE INVOLVEMENT

I am listened to and involved in planning and making choices about my care in a way that suits me.

POSITIVE RELATIONSHIPS

I have one key person

who takes ownership for coordinating all aspects of my care. They make

me aware of all the options and keep me

informed about what’s happening. They

understand me and I trust them.

EASY ACCESS

I can contact my care

coordinator when I need to. I am given access to

information, education, advice and expertise to help

manage my condition. Support and services are available as close to my

home as possible and I know there is a 24/ 7 response

available if I need it.

SEAMLESS COORDINATION

I receive seamless timely,

coordinated care with easy, efficient transitions from one service to another. Professionals across all

services have access to an up-to-date shared record of my condition, needs history and services and treatments

I am receiving.

Enablers • Caring, compassionate, competent and knowledgeable staff work in multi-disciplinary teams across organisational boundaries with up-to-date, shared records, facilitated and supported by organisations and systems.

• Patients and carers asked for feedback on services and see improvements happen as a result.

What matters

Outcomes

Representatives from all parties worked through options

Modified Michael Porter’s hierarchy of health outcomes

Focus on:

• what people say matters about their care

• outcomes representing value to commissioners and providers

Link to project aims

Tier 1: Wellbeing status Independence Wellbeing Health outcomes

Tier 2: Process of care Right care Right time, right place

Tier 3: Sustainability of services Cost Staff Learning organisation

Key Symphony Components

1. Evidence – individual level data set

2. Shared outcomes

3. Care model

Symphony - Core functions

Coordination

Self Management

support

Service user

Care provision

Key features of the model

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• Cohort of patients

• Single care plan, single pathway

• Four hubs – GP clusters

• Expert generalist medical input

• One care-coordinator - manage transition from current pathways to single pathway

• Key workers to build relationships and act as health coaches

• Intelligent use of new technology

• Support to improve health through self-management

• Early detection of crisis – wrap around health + social care

• Hospital team part of Symphony

Twitter: @andrewdstreet @SymphonyProj

Publication: goo.gl/3WvTN6